Assessment of the Acutely Ill Patient

A Dummies Guide

• Don’t panic! There are very few emergencies to which you have to run
• Taking the time to do a systematic (ABCDE) assessment is the only way to get anywhere
• If in doubt, a CXR, ECG and ABG are useful in most sick patients
• Don’t assume in confused/drowsy/unresponsive patients that this is their normal status
• Think in terms of physiology and pathophysiology

PRIMARY SURVEY – eyeball the patient – do they look sick?

Airway assessment + C-spine
• If possible trauma – protect the C-spine
• *Can the patient talk normally? (If so, the airway is patent)
• Stridor/gurgling/snoring (partial airway obstruction)
• Chest wall movement
• Feel for breath
• Look in mouth
• *Oxygen if patient sick

Airway problems:
If evidence of actual or potential airway obstruction – get anaesthetics help early
Don’t wait for O2 saturations to drop – by that stage your patient may be in big trouble
Remember airway adjuncts if inability to maintain an airway due to decreased
conscious level
Consider suctioning (call chest physio) if evidence of retained secretions i.e. gurgling
noises

Breathing assessment – look/feel/listen

• *Obvious distress?
• Use of accessory muscles?
• Cyanosis?
• *Respiratory rate (This is the single most useful marker of critical illness)
• Tracheal tug/deviation
• Chest wall movement + expansion
• Percussion
• *Air entry/breath sounds
• *Added sounds
• Vocal resonance
• *Oxygen Saturations (aim for >93%, but if <97% in a normally healthy young
person, think about why)

Breathing problems:
There are only a few things that commonly cause life-threatening breathing problems:
• Pneumonia
• COPD + Asthma (i.e. bronchospasm)
• Pulmonary oedema
• Pulmonary embolus
• Pneumothorax
These can co-exist.
O2 Saturations of 92% in a young, previously healthy patient are not ok.
Not everyone with tachypnoea has a primary respiratory problem, it can be secondary
to a metabolic acidosis or a CNS problem
O2 Sats of 97% might be ok on room air, but if it takes high-flow oxygen to achieve
this, something is badly wrong with gas exchange in the lungs

Circulation assessment (Hands-face-chest-abdomen-legs)

• *Cool, clammy/warm and flushed?
• Colour – pale? Grey? Mottling?
• *Peripheries warm or cool
• Capillary refill time
• *Central pulse – rate, volume, regular (Need SBP>80mmHg for radial pulse)
• JVP
• *BP
• Heart sounds
• ?DVT
• Peripheral oedema – ankles/legs/arms/flanks
• Peripheral pulses
• *IV access

Circulatory problems:
Shock is a failure to adequately perfuse organs, not just hypotension. Hypotension
means advanced shock.
Think of the cardiovascular system as plumbing. Things that can go wrong:
• Not enough fluid (Hypovolaemia e.g. bleeding, vomiting)
• Pump failure (Cardiogenic shock – MI, fluid overload, arrhythmia, valve disease,
cardiomyopathy, myocardial depression due to drugs or acidosis)
• Blocked pipes (Obstruction to flow – PE, cardiac tamponade, high intrathoracic
pressures)
• Leaky or poorly functioning pipes (Vasodilatation – septic shock, anaphylaxis)
• Finally, neurogenic shock - rare, due to loss of sympathetic input in C/T- spine
injuries, causing vasodilatation and bradycardia.

In most cases, fluid resuscitation is the first-line treatment for shock, but not always.
In cardiogenic shock, fluids will tend to make a bad situation worse, and the
management is to treat any immediate cause eg arrhythmia or MI, and/or use
inotropes.
Unless there is obvious pulmonary oedema, a fluid challenge is worthwhile (250-
500mls of colloid e.g. Voluven or Gelofusin over15-30mins, and assess response –
HR, BP, urine output and CVP if available). Never use hypotonic fluids e.g. 5%
dextrose for resuscitation purposes. If bleeding + hypotensive, use blood, ideally
cross-matched.

Disability assessment
Quick neurological screen – time to do a full assessment later:
• AVPU score – Alert/Repsonsive to Voice/Responsive to Pain/Unresponsive
• Pupils – equal & reactive?
• *GCS (E,M,V) esp. posturing
• *Check capillary blood glucose

Disability problems
New focal neurology? Is it haemorrhage? – this is the most treatable cause.
Generalised deterioration in conscious level- 1° CNS cause, or a response to other
pathology?
Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of
other things for which sedation is not the treatment.
Check capillary blood glucose

E-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS)

History (Chest pain/SOB/palpitations/thirst/pain/fatigue/dizziness)
Examine abdomen including for AAA, Neuro or other exam as indicated
Input/output chart – consider urinary catheter and hourly urometry
Medications
CXR / ECG / ABG / Blood tests / Other investigations – as indicated
ABG analysis is not just for diagnosing respiratory failure – it gives information on
perfusion and lots of other useful things.
Find out normal state – ask nurses/check notes/call relative
Are they an ICU/HDU candidate? If so, inform them early.
Are you competent to deal with this patient by yourself?

Specific Management of Some Common Emergencies

Cardiac Arrest (http://www.resus.org.uk/pages/guide.htm)

Basic Life Support (BLS):

Call for Help
A: Head tilt + chin lift/jaw thrust. Clear mouth.
B: If not breathing - give 2 breaths
C: If no pulse - give 15 chest compressions at 100/minute, per 2 breaths.

Advanced Life Support (ALS):

If witnessed arrest - give Precordial thump.
BLS.
Attach defib/monitor.
If VF or pulseless-VT => DC Shock 200, 200, 360 joules; CPR 1 minute; reaccess
rhythm & pulse; reshock 3 x 360 joules.
If non-VF or VT-with-pulse => 3 minutes CPR; reassess rhythm & pulse.
During CPR: correct reversible causes, IV access, give 1mg IV Adrenaline each 3
minutes, consider intubation.
Consider amiodarone, atropine, pacing, buffers.

Reversible causes:
Hypoxia
Hypovolaemia
Hypokalaemia, hyperkalaemia
Hypothermia
Tension pneumothorax
Tamponade
Toxic/therapeutic disturbance
Thromboembolic/mechanical obstruction.

2. Myocardial Infarction

Management: (BOOMASS)
Bed rest
Oxygen
Opiates
Monitor rhythm (ECG)
Aspirin (300mg) (GTN and Beta-blockers can help)
 Steptokinase or tPA (if within 12hr and elevated ST, but no contraindications)
Stop smoking (exercise, diet, physio)

In more detail:
ECG Monitor
O2 (High flow)
IV Access.
FBP, U+E, Glucose, Lipids, Cardiac enzymes.
Aspirin 300mg
Morphine (5-10mg IV) or Diamorphine (2-5mg IV) + Antiemetic, eg: Metoclopramide
(10mg IV)
GTN spray or Buccal Suscard (unless hypotensive)
Beta-blocker (eg. atenolol 5mg IV, unless asthma or LVF)
Thrombolysis (Streptokinase or Alteplase, rt-PA) - if within 12 hrs (still may help up to
24 hrs) and ST elevation, BUT no internal bleeding, no surgery in past 2 weeks, BP not
over 200/120mmHg, previous allergic reaction, pregnancy, don't give streptokinase if it
is 5 days to 1 year since last administration. If there are thrombolysis contra-
indications, consider urgent angioplasty instead.
CXR
Prophylaxis - Management of any existing Diabetes, DVT Prophylaxis
Stop Calcium channel antagonists
Contraindications to Thrombolytics (Variation between clinicians – these are
typical):
Recent trauma/surgery
Bleeding disorder
Head injury
Previous haemorrhagic CVA
CVA within 6 months
Brain tumour
Active peptic ulcer
Active bleeding (not menstruation)
Prolonged CPR
Warfarin therapy (relative C/I)
3. Acute severe Asthma (http://www.brit-
thoracic.org.uk/c2/uploads/asthmafull.pdf)

Signs of Severe attack:

Cannot complete sentences
Resp rate > 25/minute
Pulse > 110/minute
Peak flow < 50% of predicted or best

Signs of Life-threatening attack:

Peak flow < 33% of predicted or best
Silent chest, cyanosis, feeble respiratory effort
Bradycardia or Hypotension
Exhaustion, confusion, or coma
Normal or high PaCO2, Low PaO2, Low pH.
Treatment:
Sit patient up,
100% O2
Salbutamol (5mg) with O2. Repeat continuously if needed.
Hydrocortisone (200mg IV)
Ipratropium Bromide (500mcg) neb.
Consider Magnesium infusion, Aminophylline or salbutamol infusion.
If severe, warn ITU.
CXR - exclude pneumothorax.
4. Anaphylactic Shock

Symptoms & signs:

Skin: Itching, Erythema, Urticaria, Oedema.
Breathing: Wheeze, Laryngeal obstruction.
Heart: Tachycardia, Hypotension.

Management:
Secure Airway
High-flow Oxygen
If respiratory obstruction imminent – intubation & ventilation
Adrenaline IM, 0.5ml of 1:1000 (=0.5mg), repeat each 5 minutes if needed
IV Access
Chlorpheniramine 10mg IV
Hydrocortisone 200mg IV
IV fluid resuscitation with saline or colloid (eg 500ml per 15 minutes). Be guided by
response to successive fluid challenges
If wheeze, treat for asthma.
May need ventilatory support, and Intensive care.

5. Diabetic Ketoacidosis
Dehydration is more life threatening than any hyperglycaemia.
Signs & symptoms:
Polyuria, lethargy, hyperventilation, ketotic breath, dehydration, vomiting, abdominal
cramp, coma.

Management:
ABCDE. Expect tachypnoea and signs of dehydration +/- shock
IV Fluids (Saline 1 litre stat, 1L over 1hr, 1L over 2hr, 1L over 4hr. Careful if >65years
or CCF. Dextrose saline when glucose<15mmol/L). Be guided by the response.
Plasma glucose. If > 20mmol/L give 10 units soluble insulin (actrapid) IV.
Tests: Lab glucose, U+E, HCO3, osmolality, blood gases, FBP, blood culture, urine
ketones & MSU.
NG Tube if nausea/vomiting/unconscious.
Insulin sliding scale with hourly blood glucose tests.
Potassium replacement – be guided by regular U+E measurement

6. Acute upper GI bleed

Assess for shock:

Cold nose and fingers
Slow capillary refill
Pulse>100/min
Systolic BP < 100mmHg
Urine output < 30ml/hr

If shocked:
Protect airway. Nil by mouth.
2 large cannulae.
Draw bloods (FBP, U+E, LFT, glucose, clotting screen).
Cross-match 6 units.
High-flow O2.
Rapid IV colloids
 If still shocked: group specific or O-ive blood until cross-match.
(If not still shocked and not liver failure, IV saline to keep lines open).
Correct clotting: Vit K, FFP. Be guided by clotting screen results.
Monitor vitals each 15 minutes, and urine output (>30ml/hr).
Notify surgeons (Endoscopy for diagnosis/control bleeding).

7. Respiratory Arrest
Call Crash Team
Open airway – position, manoeuvres, adjuncts
Bag-valve-mask ventilation with supplementary oxygen
Definitive Airway – LMA or ETT
8. Ischaemic Chest Pain
Morphine
Oxygen
Nitrate
Aspirin
9. Pulmonary Embolus
• A/B/C/D as usual
• Oxygen
• Fluid challenge if shocked
• ABG/CXR/ECG
• LMW Heparin eg Enoxaparin 1.5mg/kg SC OD
• If shocked or hypoxic despite high-flow oxygen – consider thrombolysis or surgical
embolectomy
• TED stockings
• VQ scan or CT Pulmonary Angiography to confirm diagnosis
• Warfarin for 6 months

Scenarios
See how you would handle some real life situations. How much have you learnt
from your experiences and reading the summary above?

For each case, discuss your assessment and management – you may have enough
information already to tell you what action to take. It’s not about the diagnosis, it’s
about assessing and managing ABCs. For exams, a good way to phrase your answer
is:

“I would go immediately to see the patient and assess airway, breathing,

circulation and disability before taking a full history, performing a full
examination and appropriate investigations. In this case, the patient’s airway…”

1. You are called to see a 38-year old patient who has been admitted
2. You
following an overdose are asked to admit
of benzodiazepines Una
and Johnston,
alcohol. His aGCS
45-year old known brittle
was 11 on admission,asthmatic,
and is nowwho is complaining
8. The nurses are of chest tightness and
concerned
breathlessness. She has been given a 5mg salbutamol neb in
that he is making loud snoring noises and his oxygen saturations
are 88% on room air. casualty, which helped a little.
3. You are called to see Mrs Jones (68) in the fractures ward where she is
day 1 post-DHS. She is short of breath. Her current medications
include furosemide, rampiril, and spironolactone tablets, and
salbutamol, ipratropium bromide and budesonide nebs.

5. James Brown is a 24-year old with Down’s syndrome, who was admitted
4. Mr Gumble
with a chest(52), a long-term
infection alcoholic, was
and commenced admitted with
on amoxicillin. Youhaematemesis.
are called th
He was haemodynamically stable on admission, but has
because his temp is now 39.1, and the nurses think you shouldjust filled his 4
take
kidney dish with bright red blood.
blood cultures. He’s a bit drowsy and you think he doesn’t seem too
well.

6. Mary Ryan is a 78-year old who is day 2 post-op and gives an 8-hour hx
of shortness of breath and mild central chest pain. Her ECG was
normal this morning. She has no past medical history, but appears
very short of breath, and is sweating profusely.

7. Karl Barth is an 84-year old with mild dementia who was admitted 10
days ago with acute exacerbation of his COPD. He responded well to
treatment with 28% oxygen, regular salbutamol and ipratropium
bromide nebs, co-amoxoiclav and prednisolone and is waiting for a
bed in a private nursing home. You are asked to prescribe
something to settle him down, as he appears very agitated tonight.
Scenarios (Answers)
1. You are called to see a 38-year old patient who has been admitted following an
overdose of benzodiazepines and alcohol. His GCS was 11 on admission, and is
now 8 (E2M5V1). The nurses are concerned that he is making loud snoring noises
and his oxygen saturations are 88% on room air.

Assess ABCs. In this case – stop at A. His deteriorating conscious level means his
AIRWAY IS COMPROMISED. Management – airway opening manoeuvers, Guedel
or nasopharyngeal airway, high-flow oxygen. Roll the patient on their side to
prevent aspiration. Arterial Blood Gas – Hypoventilation will make CO2 rise long
before O2 falls, so he may already have a respiratory acidosis. Chest X-ray – has he
already aspirated? Consider ICU assessment for further airway management. Don’t
forget to finish your assessment after fixing A – B, C and D + secondary survey.

2. You are asked to admit Una Johnston, a 45-year old known brittle asthmatic, who is
complaining of chest tightness and breathlessness. She has been given a 5mg
salbutamol neb in casualty, which helped a little.

Assess Airway – clear. Breathing – unable to complete sentences. RR42. Using

accessory muscles. Not cyanosed. Sats 91% on 35% oxygen. On examination of her
chest – decreased air entry throughout, wheeze throughout.
From above – at least 1 life-threatening feature of ACUTE SEVERE ASTHMA present
according to BTS guidelines.
Management - Switch to high-flow oxygen. Check PEFR if possible.
Nebulisers – salbutamol 5mg continuously depending on response, atrovent 500
mcg as one-off.
Assess circulation and obtain IV access. These patients may be septic or grossly
dehydrated.
IV Hydrocortisone 100-200mg or oral prednisolone 40mg.
Check ABG, FBP, U+E, Mg, CRP, ECG, CXR.
ABG on 35% oxygen: pH 7.57, pCO2 2.3, pO2 10.2, HCO3 24. ECG – sinus tachy rate
120. CXR – hyperexpanded lung fields, no consolidation or pneumothorax.
IV antibiotics if evidence of infection.
Magnesium infusion 8mmol/30 mins unless rapid response to nebulisers.
Consider Salbutamol or Aminophylline infusion and
Refer to ICU unless rapid improvement. See British Thoracic Society guidelines.

3. Mrs Jones (68) day 1 post-DHS. She presents with dyspnoea. Her current
medications include aspirin /simvastatin/ frusemide/ rampiril tablets, and
salbutamol/ atrovent/ pulmicort nebs.

Tells you ‘can’t breathe’- so airway clear. RR32. Cyanosed. SaO2 83% RA, 92% on
4L. Chest – decreased air entry both bases. Creps to midzones, mild wheeze. HR
110, reg. HS1+2+3. BP 140/95. JVP 8cm. Ankle oedema. Well-perfused. No DVT.
ECG – sinus tachy. CXR- awaited. I/O 4000/350 over past 24 hours.
Management of ACUTE PULMONARY OEDEMA (But don’t usually just do 1 step
at a time):
Sit patient up
High Flow Oxygen
Frusemide 40-80mg IV (repeat after 20 mins)
Diamorphine (small dose, perhaps 2.5mg, and caution if elderly or respiratory
disease)
Nitrate (GTN spray or Buccal suscard 2-5mg s/l – but watch blood pressure)
If not responding well, consider:
Aminophylline Infusion (250mcg over 20mins)
Nitrate Infusion
CPAP
Venesection

4. Mr Barnet (52), a long-term alcoholic was admitted with haematemesis. He was

haemodynamically stable on admission, but has just filled his 4th kidney dish with
bright red blood.

Airway-clear. Speaking in sentences. RR35. Chest clear. Sats 95% on 2L nasal

specs. HR 140, BP 75/55, CRT>4sec, peripheries cold+ clammy, peripheral pulses
impalpable. Confused+agitated. No IV access. No urinary catheter.
From the above - A+B ok, but profound HYPOVOLAEMIC SHOCK.
High-flow oxygen,. IV access x 2 and take blood for FBP, Co-ag, U+E, G+X-match
at least 4 units. Start rapid colloid infusion while waiting for blood. Give IV PPI.
Catheterise and monitor urine output hourly. Contact general surgeons – needs
emergency OGD and possibly surgery
Surgeons in theatre – will be down ASAP.
1 hour later: Had 1.5 litres of colloid. Blood has just arrived. HR now 125, BP 95/70,
still cool peripheries and shut down. Urine output 5mls/hr. Still vomiting fresh blood.
FBP: Hb 9.1, WCC 7.4, Plts 34, MCV 101.2
U+E: Na 134, K 5.1, Urea 15.2, Creat 56
Co-Ag: PT 32 (12-17) APTT 55 , INR 4.1 Fib 2.1
-Continue to resuscitate with warmed blood. Developing coagulopathy Need to give
platelets/FFP/cryoprecipitate/Vit K - Contact haematologist for advice. Management is
to control bleeding – OGD +/- Sengstaken-Blakemore tube, or if bleeding cannot
be controlled, laparotomy.

5. James Brown is a 24-year old with Down’s syndrome, who was admitted with a
chest infection and commenced on oral amoxicillin. You are called because his
temp is now 39.1, and the nurses think you should take blood cultures. He’s
drowsy and you think he doesn’t seem too well.

Airway – clear. Breathing – RR 32. Sats 97% on 2L oxygen. Not distressed. Chest –
coarse creps R base. Circulation – Warm peripheries, bounding pulses, HR 150 reg,
BP 60/40, JVP difficult to assess. No ankle oedema/DVT. Disability – drowsy,
confused GCS12 E3M6V3, PEARL.
Classical picture of SEPTIC SHOCK – but not all warm and hyperdynamic circulation –
later on these patients become cold and shut down. High flow oxygen. IV access
x2. Bloods for FBP, dWCC, U+E, CRP, Co-Ag, cultures, ABG. Fast IV fluid
resuscitation. IV abx after appropriate cultures – according to local policy.
Catheterise and monitor urine output. PR paracetamol. If no response to fluids – will
need Vasopressors – high-dose dopamine or noradrenaline (in HDU or ICU). Fluid
replacement should be guided by CVP monitoring. High mortality. Complications of
shock – DIC, Renal failure, ARDS, Liver/splenic/gut infarction/CVA/MI.

6. Mary Ryan is a 78-year old who is day 2 post-op and gives an 8-hour hx of
shortness of breath and mild central chest pain. Her ECG was normal this
morning. She has no past medical history, but appears very short of breath, and is
sweating profusely.

Airway – clear. High flow oxygen. Breathing – RR 30/min. Not using accessory
muscles, Sats 85% RA, 97% on 100% oxygen. Chest – fine creps bibasally to
midzones. Circulation – HR 140 irreg. JVP 5cm. BP 100/60. HS 1+2+0. cool
peripheries, CRT 3sec. IV access, bloods for FBP, U+E, Ca, Mg, TnI, TFTs. Denies
chest pain now. Cardiac monitoring. ECG – AF, V rate 140. Diagnosis is FAST
ATRIAL FIBRILLATION CAUSING LV FAILURE. Need to treat both. Frusemide
40mg, Morphine 5mg, Commence amiodarone infusion, as this is new onset AF.
(300mg/1 hour then 900mg over 23 hours). Urinary catheter+hourly urometry.

After 1 hour – HR 170 irreg, BP 70/40, cold, clammy, shut down. Urine output 10mls.
Mild chest pain, drowsy. Now in cardiogenic shock. Unstable. Synchronised DC
cardioversion the definitive treatment +/- inotropic support with dobutamine. Will
need sedation e.g. with Midazolam.

7. Karl Barth is an 84-year old with mild dementia who was admitted 10 days ago with
acute exacerbation of his COPD. He responded well to treatment with 28%
oxygen, regular salbutamol and atrovent nebs, augmentin and prednisolone and is
waiting for a bed in a private nursing home. You are asked to prescribe something
to settle him down, as he appears very agitated tonight.

Go to see the patient. He’s talking, but not completing sentences. Breathing RR
28/min. Sats 82% off oxygen. Hyperexpanded lung fields. Wheeze throughout chest,
few scattered creps. Circulation – HR 105 reg, BP 110/70, HS 1+2+0, well perfused.
Good urine output. Disability – confused and agitated, wants to go home.
Oxygen therapy: controversial but the priority is to correct hypoxia, so whatever
concentration of oxygen it takes to maintain SpO2 >90% for most patients, but
bear in mind the O2 sats may be low at the best of times. Back to back
salbutamol nebs via compressed air + additional O2+steroids. ABG on 28%: pH
7.27 pCO2 9.1 pO2 7.9 HCO3 32. Type 2 respiratory failure. Treat with back to back
nebs, steroid, abx if evidence of infection (Temp, clinically septic, WCC, CRP, low
platelets). If not responding quickly - ventilatory support – NIPPV (Non-Invasive
Positive Pressure Ventilation), or Doxapram or intubation/ventilation. No sedation.

http://www.studentbmj.com/issues/04/02/education/56.php - useful article on oxygen

therapy

Recommended reading: Essential Guide to Acute Care.

Cooper N and Cramp P. BMJ books 2003.
Everyone should read this book before starting as a JHO – it contains lots of
information about managing sick patients that everyone should know but most
people don’t.

Jon Silversides
May 2005